Carpometacarpal Carpometacarpal OsteoarthritisOsteoarthritis

Trapezio- metacarpalTrapezio- metacarpal joint is the joint is the commonest to be affected in commonest to be affected in postmenopausal women in combination postmenopausal women in combination with heberden's nodes of the DIP joints.with heberden's nodes of the DIP joints.

Clinical features:Clinical features: Usually bilateral and part of Usually bilateral and part of generalized OA.generalized OA. Middle age women.Middle age women. Diffuse pain around thumb base.Diffuse pain around thumb base. Weak pinch and grip.Weak pinch and grip. Tender swollen joint, adducted, Tender swollen joint, adducted, grinding test painful.grinding test painful.

Plain X-ray: Plain X-ray: Shows classical features Shows classical features of OA.of OA.

Treatment:Treatment: Conservative :Conservative :{ Rest, NSAID, { Rest, NSAID,

Temporary splintage}.Temporary splintage}. Operative: Operative: {Excision and replacement {Excision and replacement

by silicone spacer, Arthrodeses}. by silicone spacer, Arthrodeses}.

De Quervain's DiseaseDe Quervain's Disease Pathology:Pathology: Thickening of the sheath around the Thickening of the sheath around the

tendons this initiated by over use or tendons this initiated by over use or spontaneously.spontaneously.

Inflammation of the synoveal liningInflammation of the synoveal lining TenosynovitsTenosynovits of the first extensor of the first extensor

wrist compartment containing tendons wrist compartment containing tendons of of (extensor polices brevis and (extensor polices brevis and abductor polices longus)abductor polices longus)..

Clinical featuresClinical features WomenWomen aged 40-50 years, also in aged 40-50 years, also in

pregnancy.pregnancy. Gradual pain at the radial side of the Gradual pain at the radial side of the

wrist.wrist. History of unaccustomed activities.History of unaccustomed activities. Tenderness over the radial styloid.Tenderness over the radial styloid. Swelling and thickening over the distal Swelling and thickening over the distal

radius.radius. Finkelstein's testFinkelstein's test is pathognomonic. is pathognomonic.

TreatmentTreatment Conservative:Conservative: Early stages with Early stages with

splintage and local long acting steroid splintage and local long acting steroid injection.injection.

Operative:Operative: Resistant cases; slitting the Resistant cases; slitting the thickened tendon sheath, be careful not thickened tendon sheath, be careful not to injure the to injure the superficial branch of radial superficial branch of radial nervenerve..

Ganglion Cysts (Dorsal Ganglion Cysts (Dorsal Ganglion)Ganglion)

Commonest cause of localized swelling around Commonest cause of localized swelling around the wrist.the wrist.

Pathology:Pathology:Leakage of synoveal fluid from a joint or Leakage of synoveal fluid from a joint or

tendon sheath contains glairy, viscous tendon sheath contains glairy, viscous gelatinous fluid.gelatinous fluid.

Clinical features:Clinical features: Young adult.Young adult. Progressively enlarging painless lump.Progressively enlarging painless lump. Commonest site s the dorsum, less common Commonest site s the dorsum, less common

volar near the radial arteryvolar near the radial artery Well defined, cystic, not tender, Well defined, cystic, not tender,

transilluminated.transilluminated.

TreatmentTreatment Conservative:Conservative: It is safe to be left, some It is safe to be left, some

time disappear spontaneously.time disappear spontaneously. Operative:Operative: If very large, painful, If very large, painful,

compress nearby nerve; surgical compress nearby nerve; surgical excision.excision.

Never give promise that it will not Never give promise that it will not recurs.recurs.

Carpal Tunnel SyndromeCarpal Tunnel Syndrome Compression and ischemia of the median nerve Compression and ischemia of the median nerve

as it passes through the carpal tunnel at the as it passes through the carpal tunnel at the wrist joint.wrist joint.

Anatomy:Anatomy: Carpal tunnel is oval in shape Carpal tunnel is oval in shape bounded posteriorly by the carpal bones, bounded posteriorly by the carpal bones, anteriorely by the transverse carpal ligament. anteriorely by the transverse carpal ligament.

ContentsContents:: Median nerve.Median nerve. Tendons of flexor digitorum superficials.Tendons of flexor digitorum superficials. Tendons of flexor digitorum profundus.Tendons of flexor digitorum profundus. Tendon of flexor polices longus.Tendon of flexor polices longus. Branch of the radial artery. Branch of the radial artery.

CausesCauses Most of the cases no definite cause.Most of the cases no definite cause. Pregnancy.Pregnancy. Rheumatoid arthritis.Rheumatoid arthritis. Trauma:Trauma:1.1. Fractures around the wrist {Colle's, Smith's, Fractures around the wrist {Colle's, Smith's,

Barton's, Scaphoid}.Barton's, Scaphoid}.2.2. Dislocations {Lunate, Perilunate}.Dislocations {Lunate, Perilunate}.3.3. Soft tissue injuries.Soft tissue injuries.

Occupational {carpenters, pneumatic drill Occupational {carpenters, pneumatic drill users, typewriters, PC users}.users, typewriters, PC users}.

Local tumors {Ganglion, Fibroma, Lipoma, Local tumors {Ganglion, Fibroma, Lipoma, Osteoma…}.Osteoma…}.

Hormonal disorders {DM, Myxodema…}. Hormonal disorders {DM, Myxodema…}.

Clinical featuresClinical features {{PainPain, , SensorySensory changes and changes and MotorMotor

disturbances}disturbances} Young & middle age, ♀-♂ ratio is Young & middle age, ♀-♂ ratio is 8:18:1.. Pain Pain in the radial side of the hand, radiating in the radial side of the hand, radiating

to elbow or shoulder, usually at night to elbow or shoulder, usually at night awaking the patient, relieved by shaking the awaking the patient, relieved by shaking the hand and lifting it up.hand and lifting it up.

ParasthesiaParasthesia & numbness along the median & numbness along the median nerve distribution.nerve distribution.

WeaknessWeakness and and

clumsiness in the hand.clumsiness in the hand.

ExaminationExamination Late: Late: Diminished sensation at median Diminished sensation at median

nerve distribution.nerve distribution. Late:Late: Obvious wasting of the thener Obvious wasting of the thener

muscles especially abductor pllicis brevis muscles especially abductor pllicis brevis {Shelf Sign}.{Shelf Sign}.

Flexion of the wrist for a wile causes Flexion of the wrist for a wile causes numbness and parasthesia in the median numbness and parasthesia in the median nerve distribution nerve distribution {Phallen's Test}.{Phallen's Test}.

Tapping the median nerve,sensation of Tapping the median nerve,sensation of electric shock in its distribution electric shock in its distribution {Tinel's {Tinel's Sign}.Sign}.

InvestigationsInvestigations (Confirm) (Confirm) Plain X-ray:Plain X-ray: Exclude bony problems. Exclude bony problems. Nerve conduction studiesNerve conduction studies: Decreased : Decreased

conduction velocity in the affected part.conduction velocity in the affected part. Electromyography:Electromyography: Deinnervation Deinnervation

potentials.potentials.

TreatmentTreatment Definitive treatment is surgery (carpal Definitive treatment is surgery (carpal

tunnel release):tunnel release):Through a volar incision, the transverse carpal Through a volar incision, the transverse carpal

ligament is incised and the nerve ligament is incised and the nerve decompressed, this done under general or decompressed, this done under general or regional anesthesia, followed by regional anesthesia, followed by physiotherapy.physiotherapy.

Conservative therapy:Conservative therapy: when surgery is when surgery is contraindicated, as in pregnancy and its only contraindicated, as in pregnancy and its only temporary {Splintage, Analgesics, Local temporary {Splintage, Analgesics, Local steroid injection (dangerous)}.steroid injection (dangerous)}.

Recently carpal tunnel release is an Recently carpal tunnel release is an endoscopic procedure.endoscopic procedure.